Provider Demographics
NPI:1144466889
Name:OSGOOD, SHANE MICHAEL (ATC, CEAS)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MICHAEL
Last Name:OSGOOD
Suffix:
Gender:M
Credentials:ATC, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2126
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-2126
Mailing Address - Country:US
Mailing Address - Phone:607-377-7850
Mailing Address - Fax:
Practice Address - Street 1:833 SHOSHONE ST N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6370
Practice Address - Country:US
Practice Address - Phone:607-377-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-5092255A2300X
NY002043-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer